Delivering bad news: Don’t pass the buck

When I was a fellow, part of our training involved doing consults for patients, most of whom had just learned they had cancer or recurrence of disease. These consults were never easy, but the importance of sitting with someone who had just learned of their diagnosis was an integral part of learning the medicine and art of oncology.

Even after many years, one call stays with me. It had come from an intern on surgical service who had called from a post-anesthesia care unit (PACU). The request was to meet with a patient who had just undergone exploratory surgery for a planned Whipple procedure. The surgery had been aborted because the patient had metastatic disease, discovered when they first entered his abdomen.

“That sounds terrible,” I said. “How did he take the news?”

“He doesn’t know. He hasn’t even woken up from anesthesia yet,” he replied.

I remember being taken aback. “Wait — so you want me to talk to your patient about his diagnosis of metastatic pancreatic cancer, and he doesn’t even know he didn’t actually have surgery?”

“Well, my attending wanted me to call you to make sure you saw him as soon as possible.”

“That’s fine, but I am pretty sure he didn’t mean before the patient had ‘woken up,’” I said. “Why don’t you call me back after your team has met with him and his family, told him that he didn’t have the surgery as planned, has stage IV pancreatic cancer, and what that means from your point of view. I assume he’ll be here tomorrow and I will see him then. I am not seeing him in the PACU, and certainly not while he is just waking up from anesthesia.”

At the time, I had bristled because it seemed to me the intern was “passing the buck,” assuming the delivery of bad news was the job of the medical oncologist. I suspected that was not what his attending had expected and that the intern was just being expedient. Instead, I had hoped that the patient’s attending wanted to be sure the patient was seen before discharge, so that his care could be appropriately coordinated. Fortunately, this latter scenario turned out to be the case.

When I think about it now, I realize that incident taught me something important — the value of a primary doctor-patient relationship, including the delivery of bad news, discussions about goals and preferences, and issues related to changes in treatment, including advance-care discussions. It was yet another watershed moment for me as a fellow, and one that has served me well.

This experience came back to me recently after an exchange with my own staff about a patient who was new to our practice. She had an advanced cancer and had come to us after she had progressed despite multiple lines of treatment. During our first visits, I had reviewed how serious her disease was and that any treatment would be palliative, not curative; and that I believed that one day she would die of this cancer. Although I was sure she was “hearing” me, it was only after multiple visits that I felt she was actually “listening.” But with each visit, I felt we were developing a clearer understanding of what her situation was.

After one such visit, a member of my team approached and asked, “Don’t you think she needs a palliative care consult?”

“Well,” I said. “I really hadn’t thought about it, but why do you think she needs palliative care?”

“I just think someone needs to talk to her about her goals and preferences. She should know she’s dying.”

This took me aback and I remember feeling angry at this suggestion. Looking back, my reaction was similar to the one from the PACU that I had so long ago. But in this, I was the one being asked to refer a job that was mine to do to someone else. But, hadn’t I been honest with this patient? Already told her how serious things were? Was it not clear to my staff that I was in the midst of those discussions on goals and preferences?

It took me a while, but I realized I had a visceral reaction to this suggestion because there seemed to be an insinuation that the “hard discussions” were no longer my responsibility. And I wondered, when did it become the job of the palliative care clinician to do this?

Palliative care has become a critical component to the comprehensive care of patients with advanced disease, and its benefits in those living with cancer have been documented in several randomized trials. Patients involved in palliative care early on in their illness appear to benefit in terms of both the quality of life and survival. As such, palliative care embraces the comprehensive care for our patients — it is attention to the physical, psychosocial, emotional, and spiritual issues of patients and their caregivers. Having the palliative care team available for my patients has improved their lives. Indeed, having them involved in the lives of my dad and my best friend made me even a stronger proponent of their involvement.

However, I remain concerned that the hard parts of oncology will be ceded to my palliative care colleagues. That the delivery of bad news, discussions of prognosis, and end-of-life discussions will be things that we, as oncologists, no longer need to do — we can just “call a consult.” Taken to the extreme, I worry that our residents and fellows will learn that they don’t need to address these issues either, because specialists are available to do the tough work for us.

This is something that we must avoid. Oncology embraces the patient’s care from the time of a cancer diagnosis to the end of their lives. It has been a privilege to care for patients during the trajectory of their illness, and some of the most poignant times in my career has been spent at the bedside of my patients as they left their lives, surrounded by their friends and families, or in the last few visits where discussion was not concentrated on the next treatment, but on the next few days, weeks, months. In my mind, to relegate that discussion to palliative care clinicians was as big a disservice as having a medical oncologist deliver bad news to a patient just waking up from surgery.

We have relationships with patients, mostly formed in the context of significant distress. Our patients rely on us for honesty and the best medical care, and that includes when things don’t look good or go as hoped. While I continue to advocate for the early involvement of our wonderful palliative care team, I feel one thing must be clear. As with any consult, we should specify what it is we are seeking from our palliative care team, and what role we would like them to play in the interdisciplinary care team for the most benefit.

I was again reminded about this recently, as I discussed a patient nearing the end of life, who had been admitted to the hospital. After hearing about my patient, including the circumstances of this admission, her prognosis, and my concerns, my colleague in palliative care (whom I had called in as a consult) asked quite simply, “How can we best support your patient, family, and your team?” It was perhaps the most valuable question and exchange I had that day, and ultimately, it framed the place of the palliative care clinician as a partner in modern oncology care.

Don S. Dizon is an oncologist who blogs at ASCO Connection, where this article originally appeared.

Delivering bad news: Don’t pass the buck 6 comments

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Patient Kit

Although I definitely see the value of the palliative care team, as a cancer patient/survivor, I would want to hear any new bad news from my oncologist who I already know and have an ongoing, trusting relationship with than hear it first from a new palliative care professional who I am meeting for the first time.

drdondizon

Hi Kit
Thanks for your thoughts. I agree- the bond between doctor and patient is quite strong, especially when one is facing a life-threatening illness such as cancer. Most of my colleagues in palliative care do not appreciate being put in a position of delivering bad news- a task best taken on by the doctor who has known the patient through much of their journey. I suppose the reality is that even though we have chosen oncology as our profession, it is not necessarily true that delivering bad news is any easier for oncologists compared to other doctors. Still, patients deserve to hear the truth- both the good news and bad- from their primary physician. That much I know is true. DSD

Patient Kit

If it makes you feel any better, I and, I’m sure many other cancer patients, understand that it isn’t magically easier for oncologists to deliver bad news. I understand that you and my awesome GYN ONC and all oncologists are human. I also understand that all of your patients have cancer, not just me. I think it takes a very special kind of person to choose to be an oncologist and to be a good one.

T H

Personally, I think that the primary care doctor needs to be more intimately involved in situations like this: if palliative care needs to be consulted, why would the consultant (oncology) send to another consultant? Why not have the patient have that conversation with their primary care doctor?

drdondizon

Hi TH. I often think about how fragmented care is when it comes to advanced illness. I think there is a way to keep the PCP involved, especially as the disease progresses. Often, especially when patients develop metastatic or advanced disease, care resorts to the oncologist and many of my own patients rarely see their PCP anymore. I still think there is value in maintaining a primary care provider, even in that situation. However, the same thing could be said of the PCP as with the palliative care physician- the delivery of bad news cannot be relegated to someone who has not been involved in the oncologic care of the patient. It’s neither fair to the patient or to the PCP or palliative care doctor. DSD

Patient Kit

I think that depends on whether the cancer patient has a good relationship with a primary care doctor — or any kind of relationship with a PCP. Many patients, including cancer patients, do not have any long-term, ongoing good relationship with a PCP. I know that I don’t. That is partly due to insurance changes that forced doctor changes. But, for years now, regardless of what my insurance was at the time, I’ve had much better relationships with my specialist docs than with my PCP. So no. I would not want to have that conversation with my PCP. I’d want to have it with my GYN ONC. Of course, I’d feel differently if I had a good relationship with a PCP.